Coronial Inquest Reveals Systemic Issues at Canberra's Adult Prison
A coronial inquest into the death of a remandee at Canberra's Alexander Maconochie Centre has heard concerning evidence about staff turnover, funding shortfalls, and operational challenges at the territory's only adult jail. The proceedings, examining the August 2024 death of 34-year-old Aubrey Agostino from a suspected drug overdose, have shed light on broader systemic issues affecting detainee welfare and prison management.
Staff 'Churn Factor' Impacts Prison Operations
Former senior director of offender reintegration Lizzie Spulak told the ACT Coroners Court that frequent turnover among experienced employees has created significant operational problems. When questioned by Coroner Ken Archer about the "churn factor" in senior staffing, Ms Spulak confirmed it had widespread effects on procedures and frameworks.
"Stuff that may have been in focus under one commissioner may not be under the next commissioner," Ms Spulak explained. "[The next commissioner] might focus on changing something else."
She described a loss of institutional knowledge and staff stability, noting that she had been responsible for writing policy despite having no prior experience in that area. The prison currently operates with what was described as a "very small" team of induction officers and just eight case managers catering to male detainees, despite a population this week comprising 458 men and 21 women.
Funding Gaps Leave Remandees Without Rehabilitation Programs
The inquest heard particularly concerning evidence about the lack of alcohol and drug rehabilitation programs for detainees on remand, who represent approximately 50 percent of the prison's population according to the 2025 Healthy Prison Review. Ms Spulak testified that there was no existing program for remandees at the time of Agostino's death and that the jail had effectively "spent all our money."
"We don't have the funding," Ms Spulak stated, explaining that ACT Corrective Services doesn't "own" their prison programs but rather licenses them from interstate services. "We looked at one from Relationships Australia, it cost $20,000 just to run it once ... and we just don't have staff."
The court heard that while a temporary harm minimisation program was implemented after Agostino's death to address drug use among remandees, it was no longer active. Evidence showed that Agostino, who told a correctional officer he was withdrawing from GHB and alcohol when admitted, was not asked about substance use during the prison induction process. A nurse had referred him to support programs, but he did not or could not access them before his death just six days after admission.
Problematic Record-Keeping System Complicates Case Management
Further evidence revealed significant issues with the prison's case management system CORIS, which Ms Spulak described as "probably one of the worst systems I've seen." The system was reportedly not user-friendly and didn't allow easy access to detainees' past records.
The court heard that Agostino's CORIS profile contained more than 2000 document attachments, with the prison's integration unit attempting to digitise footprint surveys but only attaching them as documents without uniform naming conventions. When asked about potential improvements to the system, Ms Spulak confirmed that changes would be "too expensive" and would require multiple modifications to improve access to case plans.
Broader Context of Substance Use Among Detainees
The inquest heard that a 2024 footprint survey appeared to show about 50 percent of responses from both sentenced and remanded detainees indicated alcohol and drugs had contributed to their arrest. This statistic underscores the importance of effective rehabilitation programs within the correctional system.
Throughout Tuesday's hearing, a framed photograph of Agostino smiling in a white top with sunglasses on his head was kept on a table facing the magistrate's bench, serving as a poignant reminder of the human impact of these systemic issues. The inquest continues to examine the circumstances surrounding his death and the broader operational challenges at the Alexander Maconochie Centre.
